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Clinical Care Classification

Unit 6 Assignment Instructions

Unit outcomes addressed in this Assignment:

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➢ Discuss the role of coding with the key features of an electronic health record (EHR) system and clinical document standards.

Course outcome addressed in this Assignment:

GEL-1.02: Demonstrate college-level communication through the composition of original materials in Standard English.

HI253-4: Summarize the features of health information systems used for quality coding practices.

AHIMA’s Professional Coding Approved Program (PCAP) Mapping:

Domain I. Data Content, Structure & Standards (Information Governance)

● Subdomain I.A Classification Systems

● 1. Apply diagnosis/procedure codes according to current guidelines (Bloom’s Level 3)

o Classification Systems

▪ ICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS)

o Taxonomies

▪ Clinical Care Classification (CCC)

o Nomenclatures

▪ CPT, DSM, RxNorm

o Terminologies

▪ LOINC, SNOMED

EHR and Coding Resources Comparison

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